I understand that my healthcare provider, Travis Shaw, M.D. has invited me to participate in a virtual consultation.
My healthcare provider has explained to me how the virtual consultation will not be the same as a direct consultation, due to the fact that I will not be in the same room as the healthcare provider.
I understand that there is potential risk with this technology, including interruptions, unauthorized access, and technical difficulties.
I understand that my healthcare provider and myself can discontinue the virtual consultation if it is felt that the videoconferencing connections are not adequate for the situation.
I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes (if applicable I may request the following: (1) omit specific details of my medical history/physical exam that are personally sensitive to me: (2) terminate the consultation at any time.
I have had the alternatives to a virtual consultation explained to me, and in choosing to participate in a virtual consult, I understand that a complete consultation may not be performed and I will require an in person exam prior to having procedures or surgery, should I choose to do so.
In an emergent consultation, I understand the responsibility of the telemedicine healthcare provider may be to direct my care to a local healthcare provider and the healthcare provider’s responsibility will conclude upon termination of the virtual consultation.
I understand that with any internet platform there is a risk of HIPAA violation or hacking of content in the unlikely event of internet hacking of a server’s content.
No recording will be performed without explicit consent by me and my healthcare provider.
I have read this document carefully and understand the risks and benefits of a virtual consultation and have had my questions regarding this consult explained and I hereby consent to participate in a telemedicine visit under the terms described herein.